|Year : 2022 | Volume
| Issue : 3 | Page : 300-305
Venous thromboembolism: Knowledge and awareness among students of faculties of medicine in Southeast Nigeria—A need for curriculum review
Helen C Okoye1, Theresa U Nwagha1, Lisa I Eweputanna2, Chilota C Efobi3, Eyiuche D Ezigbo4, Angela O Ugwu1, Onochie I Obodo1, Charles E Nonyelu1
1 Department of Haematology and Blood Transfusion, College of Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu, Nigeria
2 Department of Radiology, Abia State University Teaching Hospital Aba, Abia State, Nigeria
3 Department of Haematology and Blood Transfusion, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Nigeria
4 Thrombosis and Haemostasis Unit, Department of Medical Laboratory Sciences, University of Nigeria, Enugu Campus, Enugu, Nigeria
|Date of Submission||14-Dec-2021|
|Date of Decision||23-Feb-2022|
|Date of Acceptance||28-Mar-2022|
|Date of Web Publication||2-Jun-2022|
Theresa U Nwagha
Department of Haematology and Immunology, College of Medicine UNN/University of Nigeria Teaching Hospital, Ituku-Ozalla Campus, Enugu
Source of Support: None, Conflict of Interest: None
Background: The burden of venous thromboembolism (VTE) can be reduced through awareness programs, as VTE is largely preventable. Objective: We sought to determine the level of knowledge among medical students in Southeast Nigeria. Materials and Methods: We conducted a descriptive cross-sectional study in clinical students at four medical schools in the southeast of Nigeria. The pretested and prevalidated version 11 of the Ipsos-Reid questionnaire was used. Results: A total of 784 students with a mean age of 23.5 ± 3.0 years participated in the study. Our respondents showed a high level of awareness of VTE (99.1%). The majority 638 (87.6%) of the respondents correctly described vein thrombosis as a blood clot in a vein. A little more than half of them knew how clots feel in the legs (51.0%) and lungs (57.5%). Their level of awareness of possible risk factors for VTE was above 57%. The relationship between medical school and the level of perception was statistically significant ([P ≤ 0.0001. Conclusion: Awareness is high, but general knowledge was low among our medical students. This may be a call to curriculum adjustment in our medical schools.
Keywords: Awareness, knowledge, medical students, venous thromboembolism
|How to cite this article:|
Okoye HC, Nwagha TU, Eweputanna LI, Efobi CC, Ezigbo ED, Ugwu AO, Obodo OI, Nonyelu CE. Venous thromboembolism: Knowledge and awareness among students of faculties of medicine in Southeast Nigeria—A need for curriculum review. Int J Med Health Dev 2022;27:300-5
|How to cite this URL:|
Okoye HC, Nwagha TU, Eweputanna LI, Efobi CC, Ezigbo ED, Ugwu AO, Obodo OI, Nonyelu CE. Venous thromboembolism: Knowledge and awareness among students of faculties of medicine in Southeast Nigeria—A need for curriculum review. Int J Med Health Dev [serial online] 2022 [cited 2022 Jul 1];27:300-5. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/300/346427
| Introduction|| |
Venous thromboembolism (VTE) is an abnormal clot formation within the venous vasculature. It comprises deep vein thrombosis (DVT) and pulmonary embolism (PE).
VTE is a preventable but often ignored cause of death, responsible for one in four deaths globally., It accounts for 60% of deaths related to hospital admissions worldwide.
The pathogenesis of VTE is complex and consists of the interaction between several inherited and acquired factors that predispose to the development of thrombosis. The true burden of VTE in Africa is unknown, but from a few small-scale studies, there is evidence of a high burden of VTE mainly due to acquired thrombophilic states.
PE is a dreaded complication of DVT with a high mortality rate. Among medically ill patients, the prevalence of PE ranged between 0.14% and 61.5% with a mortality rate of 40.0–69.5%. Although the clinical features of PE are non-specific and require a high index of suspicion to diagnose, the high prevalence and fatality rate in Africa compared with developed countries may be attributed to the inaccessibility of effective treatment and the challenges in diagnosis due to the absence of diagnostic facilities., Equally, the practice of thromboprophylaxis was found to be low in Africa; hence, there is a need to create awareness of VTE in this clime. There is also a need for early identification and proper management of those with DVT to prevent PE and to use thromboprophylaxis in individuals at risk of thrombosis.
In 2014, the World Thrombosis Day (WTD) group launched an awareness program to increase global awareness of thrombosis. Different groups in Nigeria, including the Enugu WTD group, have since joined to create this awareness. The Enugu WTD group University of Nigeria/University of Nigeria Teaching Hospital (Enugu WTD group UNN/UNH) joined the global move in 2017 and has been conducting an annual awareness campaign within the hospital and the university community, as well as the Enugu metropolis, to educate healthcare workers and the general public about VTE. There are limited data on awareness of VTE, especially in Nigeria. Although it did not include any African country, a recent global survey showed a low awareness of VTE, supporting the need to increase public awareness of VTE to reduce the burden of the disease. As medical students are prepared for the delivery of health care, it is essential to improve their awareness of VTE so that they can recognize VTE cases. To accomplish this, we need to determine their level of awareness. The outcome of the study will be useful in adjusting the faculty of medicine curriculum as required.
| Materials and Methods|| |
Study participants comprised students who have completed their basic sciences and have commenced their clinical training, that is, fourth, fifth, and sixth (final) year medical students. Signed informed consent was obtained from recruited students. Our choice for study subjects was based on the fact that as medical students in training, they are expected to have knowledge of VTE to be well prepared for optimal healthcare delivery to be able to identify patients at risk or recognize symptoms of VTE quickly.
We carried out a descriptive cross-sectional study on clinical students in four faculties of medicine in Southeast Nigeria. The faculties of medicine include Abia State University Teaching Hospital (ABSUTH) Abia State, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH) Anambra State, Enugu State University of Science and Technology Teaching Hospital (ESUT-TH) Enugu, and University of Nigeria Teaching Hospital (UNTH) Enugu state. The UNTH is the oldest faculty of medicine with more than 60 years of medical training, whereas the COOUTH is the newest faculty of medicine.
Our study tool was a pretested and prevalidated draft 11 version of Ipsos-Reid VTE awareness questionnaire. We used it to accumulate data on the sociodemographic characteristics of the participants, their level of awareness of thrombosis and VTE, in particular, as well as other non-thrombotic disorders, their knowledge of clinical characteristics and major risk factors. To check for over-accordance in filling the questionnaire, a non-existent term was included in the medical condition and a couple of wrong answers was included for the clinical characteristics and risk factors of VTE. We had 2 five-scale questions each of which had the top 2 response options as affirmative responses, the third response option was a neutral response option, and the bottom two response options were disagreeing response options.
Ethical approval with the number NHREC/08/2008B-FWA0002458-1RB00002323 was obtained from the UNTH Research Ethics Committee.
Sample size calculation
The sample size was calculated using Stamate version 2.00. The key assumption is that knowledge is 68% (from a previous study). A sample size of 786 has 80% power to detect an increase of 5% at an alpha level of significance of 0.05 in a two-tailed analysis.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) computer software version 24.0 for Windows to determine the frequency, percentages, and mean score for each item. Quantitative variables were analyzed using Student’s t-test or the Mann–Whitney U-test, and associations were expressed using the χ2 and adjusted odds ratio. The tests were two-sided, and the P-values were calculated to test their statistical significance (P ≤ 0.05).
| Results|| |
We had a total of 784 respondents from four participating institutions, the sex distribution in the study reveals that 428 (54.6%) and 356 (45.4%) participated, having a mean age of 23.5 ± 3.0 years; 300 (38.3%) UNTH-sourced respondents and 600 level students had higher representation in the survey [Table 1].
In finding out the awareness of the respondents about various medical conditions, we received responses in the affirmative as follows: heart attack (99.0%), stroke (99.1%), VTE (99.1%), AIDS (99.0%), PE (98.8%), hypertension (98.0%), breast cancer (99.0%), prostate cancer (98.8%), and 0.5% of the respondents were unaware of any of the conditions. Only 0.5% of the students claimed to know hemo-distension syndrome, which in itself is not a real medical condition. Using a scale to measure the degree of concern about selected medical conditions, from the lowest degree “not at all connect”to the highest degree “extremely concerned,”the proportion of respondents that indicated being “extremely concerned”was higher in all cases, including VTE, with 28.0% [Table 2].
When asked about the description of venous thrombosis, the majority, 638 (87.6%), of the respondents described venous thrombosis as “a blood clot in a vein,”51 (7.0%) described it as “tumor in the leg,”34 (4.7%) described it as “lack of oxygen in the vein,”only 1 person (0.1%) said that it was none of the descriptions listed, whereas 0.6% were not sure of any of the descriptions. Of the 775 students who responded, 395 (51.0) knew how the blood clot feels in the leg, whereas 380 (49.0%) did not. Likewise, of the 767 respondents, 441 (57.5%) knew of the symptoms of pulmonary embolism, whereas 326 (42.4%) were unaware. [Figure 1]A and B shows the frequency of knowledge of the symptoms of DVT and PE, respectively, of the respondents.
|Figure 1: A: Knowledge of the symptoms of DVT. B: Knowledge of the symptoms of PE|
Click here to view
The most common symptoms among the respondents were leg pain (399, 90.1%), leg swelling (376, 84.9%), and changes in skin color 344 (77.7%) [Figure 1]A. The most common correct symptoms among the respondents were shortness of breath (463, 96.5%) and chest pain (423, 88.1%) [Figure 1]B. Only 25.3% and 30.0% of the students wrongly selected leg itching and leg paralysis as symptoms of DVT, respectively. Surprisingly, shallow breathing was the third most frequently selected symptom (70.2%) for PE, although it was an incorrect response. Other incorrect responses to PE included pain radiating down the arm (36.9%) and frequent headache (26.9%).
When asked about risk factors for VTE, respondents opted for immobility for a long time (694, 91.8%), surgery (621, 82.1%), old age (583, 77.1%), and hospital admission (572, 75.7%) as the main risk factors. Others include smoking and diabetes (73.0%), a family history of blood clots (70.5%), cancer (64.9%), pregnancy and puerperium (61.1%), and the use of estrogen-based medications (57.1%). Again, a good number of respondents (73.3%) incorrectly chose high blood cholesterol as a risk factor. Other incorrect options are high blood pressure (49.5%), blood donation (14.6%), too much exercise (8.2%), and not sure (0.3%).
Using a five-point Likert scale to measure the level of perception of respondents about blood clots, the study reveals that most respondents, in all cases, disagree, except that 625 (83.8%) agree that “blood clots can cause death,”implying good perception [Table 3].
We found that the level of their concerns about the following health risk of a medical condition is as follows: extremely not concerned 141 (18.3%), mildly concerned 103 (13.4%), rarely concerned 125 (16.3%), concerned 150 (19.5%), and extremely concerned 250 (32.5%), interquartile range (IQR) = 3, Cronbach’s alpha = 0.9.
Respondents with high, low, and very low perception of embolism constituted 657 (86.8%), 21 (2.8%), and 79 (10.4%), respectively. IQR is 0.4. On the level of knowledge, the respondents with good, fair, and poor knowledge of VTE constituted 80 (10.2%), 263 (33.5%), and 441 (56.3%) respectively, IQR = 1, Cronbach’s alpha = 0.9. Awareness of selected medical conditions was high, comprising 769 (98.1%), IQR = 0, Cronbach’s alpha = 0.9.
The relationship between sex, class level, and VTE knowledge level among respondents was statistically significant, having P-values less than 0.05, respectively. While the adjusted odds ratio of 0.6 (95% confidence interval [CI]: 0.35–0.96) implies that the sex of the respondents does not influence the level of knowledge, being at the 400 level, with an adjusted odds ratio (AOR) of 1.5 (95% CI: 0.80–2.69), may influence the level of knowledge [Table 4].
In [Table 5], the relationship between school and the level of perception was statistically significant, having a P-value less than 0.0001. The AOR reveals that being in COOUTH influences the level of perception with 1.2 (95% CI 0.53–2.74), using UNTH as a reference.
| Discussion|| |
Our study sought to determine the level of knowledge among medical students in Southeast Nigeria. The importance of improving the knowledge base and raising the level of awareness of a disease condition in the prevention, recognition, and treatment of that particular health condition is a fundamental public health teaching. Public awareness as a very important tool to reduce the morbidity and mortality of VTE has been advocated for a very long time. VTE is a major cause of morbidity and mortality and despite this, general knowledge of VTE is found to be quite low among hospitalized patients and even poorer among the general public., This low level of knowledge among the public is perceived to be the main contributor to this high morbidity and mortality associated with VTE. As such, gaging the perception and knowledge of VTE between different groups as in our case, medical students, and making a conscious effort to bridge the knowledge gap remain a credible way of reducing the burden of VTE disease.
This study, which shows a high level of awareness, description, and risk factors for venous thrombosis, is consistent with the work done to increase awareness of VTE among physicians. Despite the lack of data on VTE knowledge specifically among medical students, the only study on VTE knowledge among medical students conflicts with this study, as it reported a lower figure in terms of the definition of disease, risk factors, and pathogenesis of VTE. It showed that 60% of the students studied could properly define VTE and an alarming 50% of the students could recognize that VTE is associated with very high morbidity. Also, very discouraging and alarming was the fact that only 52.75% of the students were able to recognize the common symptoms of DVT and therefore the need to take action to do more research.
This study shows that almost all (99.1%) medical students surveyed are aware of VTE and are extremely concerned about this medical condition. Most of them (87.6%) could accurately describe what DVT is about the lower extremities and an encouragingly high number of these medical students can adequately state the common symptoms of VTE. It was also found that a high number of medical students are knowledgeable about the common risk factors associated with the development of a VTE, as 91.8% recognized immobility as a known risk factor. This high level of knowledge is very encouraging as it can easily be translated into prompt recognition and the institution of adequate treatment of VTE when these students become medical professionals. This act of recognizing VTE, which translates into instituting treatment modalities, will go a long way toward reducing the morbidity and mortality associated with VTE.
The level of knowledge being statistically significant when compared with the class level is also in line with a similar study, and the reason is not far-fetched as these students tend to acquire more knowledge as they move up in class. Furthermore, the use of UNTH as a reference point shows a statistical significance between the level of knowledge of VTE and the medical school involved. This is especially worse in COOUTH, which is still a new medical school compared with other medical schools like UNTH that have been around and training medical students for decades.
| Conclusion|| |
Despite the high level of awareness of VTE among medical professionals, it does not translate into proper recognition of risk factors and also does not show that the medical professional knows how to adequately diagnose VTE based on risk stratification when the patient presents to the hospital., It has also been observed that there is an inadequacy of knowledge in the aspect of proper treatment guidelines and prophylactic modalities of VTE.
| Limitations|| |
Our study was not without limitations. Our study tool consisted of closed-ended questions, which may have helped study participants answer the questions. Additionally, although the recommended sample size for medical students was achieved, increasing the sample size may allow more robust conclusions to be drawn.
| Recommendations|| |
Taking into account all of this, the value of continuous teaching of VTE cannot be overemphasized and calls for continuous training and retraining. The result of this study, although very encouraging, should not be considered as a reason for the delay in terms of continuous teaching about VTE among medical students involved. Rather, it should be an encouragement to continually improve the knowledge base of these future medical professionals in terms of adequate diagnosis based on risk stratification, the ability to quickly recognize risk factors, and the ability to be informed about current treatment modalities of VTE.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]